The relationship between a social determinant such as poverty and mental health has been the subject of many scientific and political debates. Does poverty lead to mental disorders or are the latter what pushes poverty? What came first: the chicken or the egg? The most recent of these debates was the one carried out by the mental health commissioner of the Ministry of Health, Belén González, who stated that in Spain the diagnosis of schizophrenia is 12 times more frequent in low-income people than in high-income people, or that the use of antidepressants is approximately four times higher depending on social class. “We often identify that what a patient really needs is not a psychologist, but a labor lawyer. Faced with the impotence of doing nothing and the lack of time to generate a story that is more in line with social problems, we opt for the prescription of psychotropic drugs,” González pointed out before demanding sports groups instead of rubifen, feminist associations instead of sertraline, or a union instead of lorazepam.
The response from some psychiatrists was immediate. Celso Arango, director of the Institute of Psychiatry and Mental Health of the Gregorio Marañón General University Hospital, warned in a column published by EL PAÍS of the reductionism of the commissioner’s speech and was displeased by the fact that she was “only interested in some risk factors—leaving one hand, for example, cannabis—or simplifying mental disorders as a consequence of the capitalist system or social problems to the ridiculous point.”
A study published this summer in the prestigious scientific journal Nature Human Behavior With data from the United Kingdom Biobank, it has joined the intense debate by discovering a bidirectional relationship between poverty and certain mental disorders. Specifically, of the nine mental disorders analyzed, the authors found that poverty contributes to major depressive disorder and schizophrenia; while, for their part, schizophrenia and attention deficit hyperactivity disorder (ADHD) increase the risk of poverty.
“For the first time, we present evidence that poverty is a causal factor in mental health disorders. Although we have known for a long time that they are associated, these data support the statement that being poor is harmful to health and leads to mental illnesses,” Marco P. Boks, member of the Department of Psychiatry at the Amsterdam University Medical Center and explains to EL PAÍS. one of the authors of the study. According to this expert, it is not clear which comes first, mental health problems or poverty, but the truth, according to the research results, is that the relationship works in both directions.
“The evidence is overwhelming: inequality and poverty do contribute to mental illness. It is true that genetic predisposition influences mental health risk, but recent evidence suggests that the contribution of genetic background to mental health may have been overestimated, and the contribution of environment is greater than previously thought. Furthermore, genetic background is not modifiable, while poverty is largely a man-made problem,” Boks argues.
Xavier Miranda, coordinator of the Degree in Social Work at the University of Lleida and researcher in the field of social intervention in mental health, refers to the metaphor of the dangerous curve. According to this, in the same way that on a dangerous curve there will be more accidents and deaths in the long term than on a straight line, in mental health more pathologies will appear in those population groups that suffer from the accumulated presence of risk factors – such as poor nutrition, a low educational level, job unemployment or the accumulation of debts and evictions. “This exposure, combined with the lack of protective factors, predisposes people to experience situations of greater vulnerability to these types of problems,” says Miranda.
The social context and genetics
According to Néstor Szerman, a psychiatrist at the Institute of Psychiatry and Mental Health at the Gregorio Marañón Hospital in Madrid and president of the Dual Pathology Foundation, the situation is worse in the case of people who suffer from addiction and another mental disorder, what is known as dual pathology, which in his opinion “increases severity, marginalization, discrimination and stigma, all factors associated with poverty.”
Miranda, however, advocates not falling into simplifying and reductionist temptations: “We come from a historical tradition in which mental pathologies have been understood in isolation from the social and cultural context, focusing attention on the neurochemical dysfunctions of the brain. Today we know that this approach was clearly reductionist. It is convenient to learn from this and not fall into the same mistake and place ourselves at the other extreme. The social context is very important, and so is genetics.”
His opinion is shared by psychiatrist Celso Arango, who recalls that, if the study data is analyzed, it can also be concluded that poverty does not seem to have a relationship with most of the mental disorders studied. Furthermore, according to the director of the Institute of Psychiatry and Mental Health of the Gregorio Marañón General University Hospital, most of the causality between poverty and mental health would not be determined solely by the situation of economic vulnerability. “It is not that poverty per se cause schizophrenia. If not poverty, what causes these people to be more exposed to a series of risk factors. For example, stress, cannabis… Furthermore, the fact that poor people are less likely to receive protective factors, such as worse early care or worse medical care, can also increase the possibility of having schizophrenia,” argues Arango.
According to this psychiatrist, there are also factors that are very difficult to control, such as the stigma of medical professionals. Arango cites, for example, several investigations carried out in the United Kingdom that have shown in recent years that, when faced with the same symptoms, it is easier for an African-American or Caribbean immigrant – generally with a worse socioeconomic situation – to receive a diagnosis. of schizophrenia than one of bipolar disorder or major depression. “In other words, racial stigma also makes it easier to receive a worse mental health diagnosis,” says Arango.
Prevent poverty and mental disorders
That some mental disorders lead to more precarious situations, as demonstrated by the study published in Nature Human Behavioris also a widely researched reality. Not in vain, according to the latest report The employment of thepeople with disabilitiescarried out by the National Institute of Statistics (INE) with data from 2022, mental disability is the one with the worst job placement rate. Specifically, only 18.9% of people diagnosed with a serious mental disorder in Spain have a job. And according to a study published in 2023 in the journal The Lancet Psychiatry With data from Denmark, people diagnosed with a mental disorder work 10.5 years less compared to the general population, although there are disorders such as schizophrenia that cause those who suffer from it to lose an average of 24 years of working life.
“The situation is even worse in Spain, which is a country in which the philosophy is: either you are perfectly fit to work or you don’t work. There is very little employment for people with disabilities, which explains why, with the same disability, here in Spain there are much fewer people working than in other countries like Sweden,” argues Celso Arango. An opinion shared by Xavier Miranda, who considers that positive discrimination measures in the ordinary labor market “are insufficient and the existing ones, such as the General Disability Law, do not work.” For the researcher from the University of Lleida, in the case of people who are already experiencing a serious mental disorder, it would be necessary to “increase the number of specific recovery programs at the community level, which involve positively influencing the work dimension, housing, leisure, etc., so that these people can achieve the most satisfactory life possible.
Néstor Szerman believes that public policies in the field of mental health should adopt the biopsychosocial model and directly address people vulnerable to suffering from mental disorders. “This primary prevention should identify from an early age families with a high density of serious mental disorders, including addictive disorders. These families already suffer on many occasions from a situation of socioeconomic adversity that represents a real challenge for prevention,” explains the president of the Dual Pathology Foundation. In these vulnerable and at-risk population groups, Xavier Miranda advocates developing secondary prevention actions that promote the maintenance of health and the strengthening of protective factors. “For example, in people with debts or problems paying the mortgage or financial difficulties, a social intervention to provide support and help in the management of said situation can be very effective,” says Miranda, who considers that, in more general terms, , all those policies aimed at reducing the economic insecurity of the population and supporting families in raising children “will have a positive long-term impact in terms of mental health.”